Fillable DISABILITY VERIFICATION FORM

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DISABILITY VERIFICATION FORM

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The DISABILITY VERIFICATION FORM form is 1 page long and contains:

  • 2 signatures
  • 27 check-boxes
  • 21 other fields

Country of origin: OTHERS
File type: PDF

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Bldg 313, Irvine, CA, 92697-5250
949.824.7494 949.824.3083 fax
DISABILITY VERIFICATION FORM
Please provide the following information in order to help us determine reasonable educational and physical
accommodations:
1. Diagnosis:____________________________________________________________________________________
If applicable: DSM V Code:___________________________ Severity: Moderate Severe Remission
2. This condition substantially limits the following major life activities: (Required)
Class Attendance Caring for Self Communicating Concentrating
Hearing (attach audiogram) Interpersonal Skills Social Interactions Sitting
Meeting Deadlines Managing Distractions Managing Stress Stamina
Memorizing Organization Perform Manual Tasks Reading
Sleeping Processing Information Taking Class Notes Writing
Visual Impairment (attach prescription) Blind
3. List other limitations/information helpful in determining accommodations in an educational setting:
__________________________________________________________________________________________
__________________________________________________________________________________________________
4. Medication Side Effects:______________________________________________________________________
5. Duration: Permanent (lasting longer than 6 months) Temporary – End Date:_____________________
6. Date of Diagnosis:_________________________________ Date of last contact:_________________________
Student Name
(Please PRINT clearly)
_______________________________________ Birthdate _______________
I am requesting academic support services through the Disability Services Center at UCI. They require current and comprehensive
documentation of my disability and functional limitations. Please respond to the following questions as soon as possible and return to
me or send by mail or fax. I authorize the Disability Services Center at UCI to contact you if clarification is needed.
Student Signature ______________________________ Date ____________ UCI ID # _______________
SECTION I: To be completed by student
SECTION II: To be completed by professional only
I understand that the information provided in this form will become part of the student record subject to the Federal
Family Education Rights and Privacy Act (FERPA) of 1974 and may be released to the student upon written request.
Name of Physician or Certified/Licensed Professional: ____________________________________________________
Title/Specialty:____________________________________ License or Certification #:__________________________
Address:______________________________________________ City________________________________________
State:_______________ Zip Code:___________________ Phone Number:_____________________________________
I verify that the above information is complete and accurate to the best of my knowledge and certify that I am not
related to this student.
Signature of Physician or Certified/Licensed Professional:____________________________________ Date:___________
lkp 06/2017
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DISABILITY VERIFICATION FORM

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Completed 4 September 2021

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